Friday, September 17, 2010

Ortho Corruption

This story about orthpedic surgeons not disclosing financial ties to the medical device manufacturers in their scientific papers is nothing new. Lack of transparency plagues the medical literature, especially in lucrative, product-driven fields like ortho and cardiology. What struck me were two points.

One, over half of orthopods who accepted over a million dollars from device companies in 2007 did not disclose this information in articles they published in the subsequent year. That's astounding. And illegal according to anti-kickback laws.
The medical device industry's practices were so flagrant that they prompted an investigation by the Justice Department. Indeed, the payments reported in the new study appear in Internet listings set up by five big orthopedic device makers — Zimmer, DePuy Orthopaedics, Biomet, Stryker and Smith & Nephew — as part of a September 2007 settlement that capped a federal inquiry of company kickbacks to doctors. Zimmer, DePuy Orthopaedics, Biomet and Smith & Nephew also paid the government $311 million in penalties.

Secondly, the amount of money is just staggering. The study from Archives of Internal Medicine indicates that 41 orthopods were paid a total of $114 million, with pay outs varying between $1-$8 million to each surgeon. My God, I chose the wrong specialty.

The good news is that there is some law that will go into effect in 2013 whereby a government database will keep track of doctor gifts/payments of more than $10 bucks. So we have that going for us. Which is nice.

Thursday, September 16, 2010

Get Rid of the 4th Year of Med School

A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.

There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.

Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?

Wednesday, September 15, 2010

NSQIP Appendicitis Data

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database has yielded some great ammunition to my preferred side in the ongoing open/laparoscopic appendectomy (OA/LA) debate. In this paper, over 17,000 cases of appendicitis were reviewed from 2008. Interestingly, over 14,000 of the appendectomies were performed laparoscopically, indicating a sea change in OR strategy on a wide scale. Pertinent findings:
*Shorter OR time for LA
*Lower incidence of superficial and deep surgical site infections with LA
*Shorter hospital stay for LA
*Significantly lower mortality in the LA group

Finally, the surgical literature is catching up with the facts on the ground. For the life of me, I just don't understand why any surgeon would want to make a McBurney incision anymore.

Tuesday, September 14, 2010

Surgical Buy In

Pauline Chen had a post in the Times last week about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction. Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example--- a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.

Dr. Chen talks about this concept called "surgical buy-in" where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It's our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.

There's an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: "If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren't improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?"

It's a great idea. As long as we restrict the protocol to those complex operations. I'd hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.

Monday, September 13, 2010

Obstetric Trauma on Healthbeat

An interesting thread developed last week at Maggie Mahar's Healthbeat blog regarding a guest post by one Jordan Grumet, an internist in Chicago, writing about an experience he had while a medical student rotating through OB/gyn.

He writes about a patient in the third trimester of pregnancy who arrived in the trauma bay bleeding profusely from a stab wound to the neck. As the trauma team fought to control the bleeding, Grumet's chief resident donned a gown and grabbed a scalpel. The woman's blood pressure dropped. The fetal monitor showed deccelarations in the baby's heart. I'll let Dr. Grumet describe the rest.
My chief cleared her throat: "Okay, guys, we're gonna lose the baby if we don't do something fast!"

Without taking his eyes from the patient, the trauma surgeon said authoritatively, "We can't. If you cut her, she'll die. Give us a minute."

"It will take a minute-and-a-half to have this baby out," said my chief. She got no answer.

She stood poised over the patient's abdomen, arm raised, scalpel in hand and ready to pounce.

The patient's blood pressure dropped even faster, and the baby's heart rate plummeted.

"It's now or never," said my chief. Then the cardiac monitor began beeping.

"Ventricular fibrillation!" The ER physician grabbed the cardiac paddles and shouted, "Clear!"

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back--and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.

Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene.

My initial comment on the post was this:
I work as a trauma attending. In obstetric trauma, the mother always takes precedence----the single biggest determinant of fetal survival is mother survival. This is Trauma Surgery 101. Once the mother progresses to unsalvageability, there is some evidence to suggest that post mortem delivery of the baby can lead to meaningful survival, albeit at meager rates of success.

Maggie Mahar responded by averring that such guidelines "must be a mistake". I then posted a second comment, politely reminding her that simply disagreeing with the evidence based, algorithmic approach to major trauma purely on emotional grounds is not a credible argument. I even posted a power point presentation I give for CME at one of my hospitals on obstetrical trauma. Pay particular attention to slide #15.

Maggie then posted a final comment where she basically just reiterated her contempt for established trauma practice. She gave no indication that she reviewed any relevant literature or even the power point link that I provided.

If the mother is hypotensive, the baby also is not getting enough blood flow. Hence oxygen exchange is compromised at the placental level. In layman's terms, if the mother is unstable, the baby is in just as much trouble. The fastest way to improve a baby's condition is to make the mother better. Maggie is seemingly unaware of the fact that a c-section requires an actual incision in a mother's belly. Furthermore, anticipated bleeding from a c-section, even in ideal circumstances, is generally expected to be around a liter. So not only would trying to perform a c-section in a hemodynamically unstable, actively bleeding pregnant woman be negligently unwise, it would arguably venture perilously close to the realm of criminal assault.

Maggie Mahar does great work analyzing the intricacies of health care policy and reform but in this particular post she has written irresponsibly. If you're going to use a wide platform like Healthbeat to write about actual medical practice, then you have a journalistic obligation to do so in a much less capricious fashion.

Sunday, September 12, 2010

Sunday Quote

Every summer vacation I re-read the Meditations of Marcus Aurelius. It always reinvigorates my heart and prepares my mind for the inexorable vicissitudes of life. A few choice selections:

"Adapt yourself to the things among which your lot has been cast and love sincerely the fellow creatures with whom destiny has ordained that you shall live."

"Loss is nothing else but change, and change is Nature's delight."

"What more do you want, man, from a kind act? Is it not enough that you have done something consonant with your own nature- do you now put a price on it?"

"When you arise in the morning, think of what a precious privilege it is to be alive--to breathe, to think, to enjoy, to love."

"Remember that man’s life lies all within this present, as it were but a hair’s-breadth of time; as for the rest, the past is gone, the future yet unseen. Short, therefore, is man’s life, and narrow is the corner of the earth wherein he dwells."

"Each of us lives only the present moment, and the present moment is all we lose."

"The soul is dyed by our thoughts."

"Perfection of character is this: to live each day as if it were your last, without frenzy, without apathy, without pretence."

Bucks Roll

Just for Drackman.

Friday, September 10, 2010

Quote of the Day

"A democracy cannot exist as a permanent form of government. It can only exist until the voters discover that they can vote themselves largesse from the public treasury. From that moment on, the majority always votes for the candidates promising the most benefits from the public treasury with the result that a democracy always collapses over loose fiscal policy, always followed by a dictatorship. The average age of the world's greatest civilizations has been about 200 years. These nations have progressed through this sequence: From bondage to spiritual faith; From spiritual faith to great courage; From liberty to abundance; From abundance to selfishness; From selfishness to apathy; From apathy to dependence; From dependence back into bondage." - Alexander Fraser Tytler.

(h/t Daily Dish).

Update: Joe Sucher has informed me that the provenance of the above quote is in dispute. See the wikipedia article on the author for the details. Anyway, I thought it was a good quote.

Tuesday, September 7, 2010

Anachronistic Specialties?

The NY Times has jumped all over a couple of recent scientific articles asserting that certified registered nurse anesthetists (CRNA's) provide equivalent care as MD anesthesiologists. Already, it is legal in 15 states for CRNA's to dispense anesthesia without the overarching supervision of a physician. Furthermore, a study from the Lewin Group in California has demonstrated that CRNA-only models of anesthesia provision are far more cost effective that our current dual profession paradigm.
In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system.

This is a fascinating debate. And I expect MD anesthesiologists to fight for their interests tooth and nail.

To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration of anesthesia occur at a paltry rate of 1/250,00 cases nowadays. This remarkable improvement can be attributed solely to technical improvements in the monitoring of patients during a procedure. Things like continuous pulse oximetry, end tidal CO2 monitoring, and fiberoptic-based intubation equipment have almost completely eliminated major morbidity from the profession. This is a good thing. But maybe not so good for anesthesiologists. They practice in a very algorithmic, checklist-based manner. Thus, it was relatively easy to teach their methods to CRNA's during a period when the exponential rise in operative case loads made it necessary to incorporate "anesthesiology assistants" into a practice, thereby allowing one attending physician to cover multiple rooms. That recent studies have confirmed what everyone else in the OR already knew---that it didn't really matter who was behind the drape while a cholecystectomy was ongoing---- is hardly a surprise. The less variability in clinical excellence one sees from certain specialists, there seems to be a commensurate decrease in perceived prestige. In other words, one's individual reputation as a doctor can be paradoxically harmed when the overall complication rate of your chosen specialty is so low. You are seen as a mere "cog in the machine", a cog that could easily be interchangeable with another doctor or, in this case, a CRNA.

Anesthesiology represents the easiest target. But don't think that the other specialties are exempt from possible onslaught. The more specialized we become as doctors, and the less we emphasize and reward doctors who focus on a holistic approach to medicine (primary care, internists, general surgeons) the easier it becomes for the federal government to replace those pricey specialists with back door, non-MD options who happen to be much less expensive. Imagine an "certified orthopedist" training program that one could enroll in directly out of college with a bachelors of science. You then spent the next three years doing nothing but learning musculoskeletal anatomy/pathology and practicing the basic orthopod operations in virtual reality and on actual patients. Perhaps actual orthopedic surgeons could be enticed to head up such a training program so that these ortho technician graduates learned their techniques from the best. Further imagine that research papers would be published demonstrating equivalent outcomes no matter who performed your knee replacement, MD or ortho technician.

It isn't difficult to see where all this is heading. The cost of healthcare must be controlled to prevent bankrupting our country. Medical school graduates overwhelmingly opt out of primary care and internal medicine. If you can't force or entice our brightest students to stop applying for derm and ortho and radiology residency slots, then maybe you can at least give them a little competition for that business from non-MD sources....

Monday, September 6, 2010

No Surprises

In the most unsurprising development of health care reform----the Obama iteration that awkwardly tries to fuse private and public coverage plans, thereby preserving the billion dollar health care "insurance" industry---- it has become apparent that the increased costs employers expect to pay for health care have simply been passed on to its employees.
Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.

Workers also increasingly face higher deductibles, forcing them to pay a larger share of their overall medical bills. “The long-term trend is pretty clear,” said Drew E. Altman, the chief executive of the Kaiser foundation, which conducted the survey this year with the Health Research and Educational Trust, a research organization affiliated with the American Hospital Association. “Insurance is getting stingier and less comprehensive.”......companies expect that their costs will only go up more under the new health care law because it requires them to provide more benefits, like coverage for preventive care.

Unbelievable isn't it? Who would have thought that for profit entities would do everything in their power to stay in the black. Given the choice to pay the higher health care costs out of a healthy profit margin versus freezing employee wages and earnings, it's hardly surprising that the private sector opts for the latter.

Simply mandating that companies pay for health care without articulating a method of subsidizing it or controlling the escalating cost of health care provision (beyond vague, unspecific programs like the Independent Payment Advisory Board) is not a viable long term solution to the crisis. That is the failure of Obamacare.

Friday, September 3, 2010

Cool Labor Day Tune

Have a great weekend...... LCD Soundsystem.

Making it Easier to Sue!

Rumors abound of a plan to revise the federal tax code in such a way that will benefit those poor, struggling plaintiff's attorneys. A bill introduced by Arlen Specter, currently being bandied about Congress, would allow personal injury lawyers to deduct costs accrued during the pre-trial and trial phases of a claim.

Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.

From the Washington Legal Foundation's Walter Schwartz:
If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.

That's just fantastic.

Tuesday, August 31, 2010

Prostate Snatchers?

Interesting article in NY Times today from Dana Jennings reviewing a book called "Invasion of the Prostate Snatchers". (Yeah, that's really the title---I suspect publishers nowadays are contractually obligated to come up with the most outrageously sensationalistic titles possible prior to shipping them off to Borders.) Jennings is a prostate cancer survivor who underwent a radical prostatectomy. His particular tumor was a highly aggressive variant. Surgery probably added years to his life. But according to a recent NEJM study, only 1 out of 48 patients with early prostate cancer who undergo a prostatectomy realize any survival benefit compared to non-operative treatment.

Here's a line that jumped off the page at me:
“Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”

That quite an astounding proclamation. 80% of the prostatectomies done in this country are arguably unnecessary? Whatever are we going to do with the million dollar DaVinci robotic machines that every private hospital is clamoring to buy and market?

Admittedly, I'm a no expert in prostate cancer. I'd love to hear a rebuttal from any urologists and medical oncologists out there.

Here's a nice review on early stage prostate cancer from the NCI. It seems that men with prostate cancer younger than 65 years old probably benefit from a more aggressive surgical approach. The older patients don't see a statistically significant benefit from radical prostatectomy.

It's never easy....

The life of a general surgeon is one fraught with contingency, soul-crushing doubt, unexpected disaster, and overwhelming stress. I wouldn't wish it upon my worst enemy. Fortunately, I was brainwashed to a sufficient degree during residency such that I actually don't mind my job.

One of the reasons general surgery is so tough is that it is nearly impossible to map out your week according to a strict schedule. Maybe at some point in a career, when you're the established, Big Kahuna of the group, you can load up your work week with elective breast biopsies, hernia repairs and lap choles and leave the middle of the night disasters for your more junior partners. In general, however, most surgeons never reach this stage of "easy livin'". It's a lifetime of inconvenience and last minute alterations and ulcer inducing pressure. If you're worth anything as a surgeon, you figure out a way to make things work.

Beyond the scheduling squeeze, the actual business of doing surgery can get to be pretty nerve wracking, no matter how routine the procedure. Anatomic variants, sick patients, hostile abdomens, and the inexorably crushing statistical likelihood of complications (no matter how careful you are) all contribute to the inordinately tight sphincters of surgeons even during the seemingly routine elective gallbladder or breast biopsy.

A few weeks ago I had one of those cases that take a few years off your life. An older thin lady visiting from New Mexico presented to the ER with a partial large bowel obstruction. Her ileocecal valve was incompetent so we were able to decompress her with an NG and prep for colonoscopy. The scope showed a partially obstructing lesion in the hepatic flexure of the colon. She had had a Whipple procedure back in the 80's for benign disease so I planned to do a standard open right hemicolectomy.

The surgery went beautifully. She was one of those thin old ladies with very little intra-abdominal fat. Even her mesentery was an ochre yellow sheet of semi-translucent tissue, like a smudged window in the attic. You could see everything. The case took 45 minutes. The ileocolic anastomosis looked perfect. She then did well for the first three days. On the fourth morning, she looked like hell. She was diffusely tender and had developed an elevated white blood cell count. I'm thinking worst case scenarios----anastomotic leak, inadvertent bowel injury, ureteral transection, etc. So I take her back to the OR and encounter something entirely unexpected: 25 inches of dead distal small bowel. I resect frankly gangrenous bowel and start to investigate. First thing I notice is a lack of pulsatile flow in the area where one would normally be able to palpate the superior mesenteric artery (SMA). Then, as I start to mobilize the left colon for either a new anastomosis or a stoma, I discover a rope-like, pounding arterial branch in the sigmoid mesentery, arising from the IMA. I follow it to the transverse colonic mesentery. I think I know what's going on, but I scrub out at this point and open up the CAT scan on the OR computer and get on the phone with the radiologist. I always get a pre-op CT scan of the abdomen on patients with colon cancer. I ask the radiologist to reconstruct the images in a coronal fashion. He calls back in five minutes and confirms my worst fears.

The lady suffered from severe mesenteric arteriosclerosis. We depend on three main arteries to feed the bowels; the celiac, SMA, and IMA. Her celiac artery and SMA were both occluded by thrombus. Her IMA was open and there was a giant meandering mesenteric artery that had developed over the years to compensate for her lack of flow through the other main trunks. So when I performed an oncologic resection of her right colon cancer, I basically transected that lifeline of blood coming over from her IMA to feed her small bowel. When I scrubbed back in, her remaining intestine was starting to look worse. She didn't have a lot of time. She was about to infarct her entire intestinal tract.

While I waited for the vascular surgeon to arrive, I dissected out the SMA origin and harvested some saphenous vein. Then we revascularized the SMA via a saphenous graft coming off the IMA. The next day, her stoma looked awful and I took her back for a second look. I resected another 6 feet of small bowel. The graft had clotted on the SMA side so I did a quick throbectomy to re-establish flow. I heparinized her and said a little prayer. The graft stayed open. She ended up leaving the hospital. Her life will never be normal again. She will suffer from short bowel syndrome and severe fluid/electrolyte disturbances from the high output stoma. The graft could shut down again anytime. But she made it through this battle. I'll take it.

We wade into shark infested waters every time we press scalpel into flesh. Your eyes better be wide open and your head on a swivel. There's no such thing as routine in general surgery. If you have masochistic tendencies, then by all means come join our club. Otherwise you might be better off in dermatology.

Wednesday, August 18, 2010

First, Do Nothing

(From the New York Times)

The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.

The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.

What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?

Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.

I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.

Tuesday, August 17, 2010

My Continued Anti-Percutaneous Drain Crusade in Appendicitis

A young kid comes into the ER with 36 hours of RLQ abdominal pain. The ER scans him. The scan shows an obvious 4cm abscess next to the appendix. What do you do?


Please. Just take the kid to the OR. Use your laparoscopic suction/irrigator to wash out the abscess. Remove the appendix. Leave a JP drain if you must. The kid goes home in 1-3 days. No more sitting in the hospital for a week with a foul smelling rubber tube hanging out his side. No more prolonged courses of expensive IV antibiotics. No more interval appendectomies. These patients don't need multi-staged management strategies with multiple invasive procedures. Just operate and be done with it.

Saturday, August 14, 2010

Between Cases

Nothing more awesome than spending a Saturday night waiting in the office for the OR room to turnover so you can start the second of three cases. It's hard to do anything real productive (like dictate charts or write a serious blog post) so I tend to screw around on YouTube. Here's Chet Baker tearing things up.

Thursday, August 12, 2010

Horseshoe Abscess

These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.

What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.

Surgical Warranties

The mathematics and specific details of this article from Archives elude me to a certain (substantial) extent, but the main gist of it is this:
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.

What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.

I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.

And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.

Wednesday, August 11, 2010

Who Are the Torture Doctors?

JAMA this month has commentary piece on the ethical failure of physicians in the CIA Office of Medical Services (OMS) who helped organize, calibrate, and supervise the torture of unarmed, often innocent prisoners at Guantanamo. The principle of "do no harm" was abrogated by these lackey yahoos as they provided a professional cover to acts universally condemned throughout modern history as torture by all civilized nations.

My question is: Who are these doctors? What are their names? Are any of them practicing medicine in our country? When is anyone going to be held accountable for the despicable, embarassing, morally devastating era of American torture?

The American Psychological Association has already mounted an attempt to strip the license of a Texas pyschologist who participated in the "enhanced interrogation" of Abu Zubaydah:
If any psychologist who was a member of the APA were found to have committed the acts alleged against Mitchell, "he or she would be expelled from the APA membership," according to the letter, a copy of which was obtained by The Associated Press. APA spokeswoman Rhea Farberman confirmed its contents.

We know that Captain John Edmondson, the former Commander of the Gitmo Naval Hospital, is on record as admitting that he countenanced the forced feeding of inmates on hunger strike (an ethical lapse condemned by 262 signatories to a letter to the editor in Lancet).

What else can Captain Edmondson admit to? Is he practicing emergency medicine now as a civilian? How many of the other doctors at Gitmo are now enjoying lucrative private practice careers? Have they all done as well as former Navy Surgeon General Donald Arthur (who now commands a salary north of $400,000 working as the chief medical officer for MainLine health)?

Doctors or Technicians?

Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.

A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.

The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?

In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?

The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.

The Increasingly Unacceptable Negative Appendectomy

When I was a medical student (really, not that long ago), we were taught on our surgical rotations that one can expect to take out a significant number of normal appendixes during a career. Specifically, a 15-20% negative appendectomy rate was considered appropriate, if not the standard of care. The rationale went like this: you don't want to miss appendicitis, delayed diagnosis leads to complicated outcomes, therefore, it's worth the morbidity of an operation to remove a few normal worms along the way.

This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.

It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.

Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.

Friday, July 30, 2010

Letting Go

Atul Gawande has a great piece in the New Yorker this week about the difficult and complex management of end stage disease in terminal patients. (See, I don't always criticize the guy. He writes good stuff.) What happens when we reach the point where further treatment is futile, when death gathers momentum, threatens to overwhelm at any moment? What do we do with these brittle, emaciated, broken human beings, bodies riddled with cancer, when all the latest toxic chemotherapy options have been exhausted and there's no more surgery to offer? What do we do when these patients don't want to hear about "palliative care" and "hospice", when they get angry or accuse you of abandonment when you tell the truth about their prognoses? There has to be something else, they plead, some new trial, some miracle cure. That faint sliver of light is what they grasp for when the darkness begins overtake them. Gawande:

There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

It's a great weekend read.

Thursday, July 29, 2010

She Chose (b)

Awesome summary from Deborah Tornello.
2. If, while attending this conference, you experienced leaking amniotic fluid and felt early contractions on the morning before you were scheduled to speak, would you (a) hand the speech to someone else, ask him or her to give it on your behalf, and go straight to the nearest hospital--one that was equipped for handling high-risk mothers, premature births, and special-needs infants--and get yourself checked out by a doctor or (b) continue with your day and give the speech anyway?

Sarah Palin chose (b).

Tuesday, July 27, 2010

Laparoscopic CBD Stone Extraction

This case was sort of fun. The patient presented with abdominal pain, localized in the epigastrium and RUQ. The US demonstrated gallstones and a thickened gallbladder wall. His amylase and lipase values were extraordinarily elevated, suggesting an element of gallstone pancreatitis. Furthermore, his bilirubin and transaminases were abnormal, raising the possibility of a common duct stone. So I sent him for an MRCP which was rather unremarkable, other than showing some edema around the pancreas.

My policy on gallstone pancreatitis is to remove the gallbladder once the pancreatitis abates---on that same admission. That way there, you don't have to worry about relapse if they pass another stone while waiting to get their outpatient surgery done. So I took this guy to the OR and his gallbladder was predictably inflamed. My initial intra-operative cholangiogram (see top pic) demonstrated a meniscus sign in the distal duct and non-filling of the duodenum.

Usually this warrants a post-op ERCP to fish out the stone. But in this case, the patient's cystic duct was quite dilated (even the large clips wouldn't extend across the lumen; I had to secure it with an endoloop). So I decided to make a run at it myself. I slid a fogarty catheter through the stump and into the common duct, all the way into the duodenum. Then you inflate the ballooon and slowly bring the tip back, adjusting for tension as you go. So I did that and boomski, out popped a little yellow stone. The second pic shows a pristine biliary tree with the folds of the duodenum filling in like a coral imprint.

Monday, July 26, 2010

Gut Check

So it's a Saturday morning and you're making leisurely rounds when a consult comes in for an ICU patient. You show up at the same time as the GI guy who was also consulted. The patient is at the extreme terminus of age. You and the GI consultant review the data together. He had come in through the ER from a nursing home with mental status changes and fevers. His WBC was elevated. A CT scan done the night before showed thickening of the colon from the splenic flexure all the way down to the distal rectum. You walk in and the guy is about to be intubated. He's on three pressors, all maxed out. His belly is soft but you can't really trust your exam. The nurse states that he "just had a seizure".

-Looks pretty bad, you say.
-Yeah. I think I ought to do a quick flex sig to see if he has any pseudomembranes (a sign of c. difficile colitis)
-Ummm...doesn't really matter either way, you offer.
-Yeah, but it would be nice to know. Then we can at least start vancomycin enemas. And with you on board, depending on what the family wants...
-This guy won't be undergoing any surgery, you say. You give him one of those looks, a look that is supposed to transmit a deeper, unspoken meaning---a look that always seems to work in the movies or in bad crime novels, but never in real life. He is already paging his endoscopy team to come in with the equipment.

You move on to the next patient on your list. A little while later a code blue is announced over the intercom as you pass the endoscopy nurse wheeling the unwieldy endo cart toward the ICU.

-You might as well put that thing away, you say.

Work Hour Reform Ctd.

More from the work hour reform beat (via Health Science Blog):
The researchers reviewed 2,908 laparoscopic cholecystectomies, in which the gall bladder is surgically removed through a small incision in the abdomen, and 1,726 appendectomies to remove patients’ appendixes that were performed at Harbor-UCLA Medical Center from July 2003 to March 2009. These are the two most common operations performed by residents, and the two surgical procedures are often performed at night when residents are more likely to have worked a long shift.

The researchers compared outcomes in these two operations when they were performed during the day by surgical residents who had worked less than 16 hours and at night by surgical residents who had worked 16 or more hours. The researchers concluded that “appendectomy and cholecystectomy operations performed at night by less rested and possibly sleep-deprived residents have similar good outcomes compared with those performed during the regular work day.”

So are you telling me that surgeons do not, in fact, require nappy time if they have been awake for 16 hours prior to performing a cholecystectomy? Really? Who knew? I can't believe it. What about the cookies and milk? Has anyone done a RCT studying the effects of a bellyful of cookies and ice cold milk on a surgeon's competence? Why hasn't the Institute of Medicine investigated this? And don't be trying to pass off a Nilla Wafer as a cookie.

Thursday, July 15, 2010

Gastric Volvulus

This elderly guy presented with acute renal failure due to vomiting everything he tried to eat or drink for a week. He was rehydrated and decompressed. The images above demonstrate a complete foregut obstruction secondary to herniation and volvulus of the stomach through a large hiatal hernia. On the coronal view, you can actually see the pylorus and dilated 1st part of duodenum in the thorax.

I reduced his elephantine stomach and repaired the crural defect. I also did a pyloroplasty and affixed his fundus to the abdominal wall with a gastropexy. He was eating lukewarm hospital chicken casserole by day three. Fun case.

Tuesday, July 13, 2010


Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.

As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.

Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.

We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.

Thursday, July 8, 2010


"Thank you all for coming tonight. Special thanks to my sponsors, Rubbadub Latex Gloves Inc. and ShankRite Scalpel Ltd.

After considering all my options I have decided to remain here in Cleveland, Ohio for the prime years of my surgical career. Numerous suitors have approached me over the past 6 months and, frankly, my soul has been wracked by guilt and self-doubt. It's been incredibly humbling. There was the practice in South Beach which offered to provide authentic Shojo Zen back massages during all my laparoscopic cases, while maintaining a steady stream of polysymphonic chill music in the background. There was the group outside Georgia that promised I could operate barefoot (or flip flops at the most) and would never have to wear a tie while in the hospital. And then of course the practice in Omaha that told me they would install a miniature indoor soccer field in my office. And how could I forget the hospital group in Poughkeepsie that told me I would be allotted ten minutes to rifle through all the anesthesiologist's wallets in the locker room between my own cases without reprisal (security cameras turned off, my call) and wad whatever I could gather into my scrub pockets. Again, I was profoundly moved by what others would willing to do to acquire my services. The temptation to leave snowy, decayed, broken-down, riddled with crime and unemployment Cleveland was high.

But I've always been about winning. Perks have no effect on me. I am a winner. I don't take out gallbladders for the reimbursement. I don't come in at three in the morning for an incarcerated hernia just to fill out sixteen duplicate copies of Medicare forms. No. It's about winning, baby. Conquering that diverticular stricture. Whacking out that burst appendix in record time. Victory. Glory. It all awaits me here on the shores of Lake Erie. I can smell it."

/taped delayed interview of above transcript available on local cable access channel 324 on August 23rd.

/screw you Lebron

Complex Diverticulitis

This is about as bad as it gets. I saw an elderly lady with a chief complaint of frequent urinary infections and passage of stool per her vagina. The images above demonstrate obvious colovesical and colouterine fistulae. The CT also demonstrated significant left ureteral obstruction at the level of the pelvic inlet. What ensued was a complex multi-specialist procedure involving a sigmoid resection, hysterectomy/oophorectomy, and ureteral stenting. Good stuff.

Sunday, July 4, 2010

Happy Fourth of July!

Despite the unemployment, the corruption, the imperialistic foreign wars, the social inequality, the increasing fundamentalism and anti-intellectualism of my conservative party, and the overall uncertainty of what the future holds --- despite it all, there's no better place to live and work and raise a kid than the old US of A. Fire up the grill. Down a few pints. Have a great weekend.

(What song did you think I would use??)

EMT Loses Lawsuit for $10 Million

(via White Coat and Kevin MD)

I was incredulous to read about the case of the EMT service sued for negligence for transporting a pregnant woman to a tertiary care center in Florida. The woman went into labor in the ambulance and the heroic paramedics had to deliver a breeched 25 week-old baby and then resuscitate him en route to the hospital. The boy lived but ended up with cerebral palsy secondary to prolonged hypoxia during the delivery. The doctors and hospitals had both settled the case for $1.4 million. The EMT company didn't feel it needed to settle, thinking there was no way they could lose at trial. They lost. And the verdict was for 10 million buckaroos.

Apparently, the plaintiffs attorney was able to successfully argue that the paramedics ought to have performed a thorough, independent evaluation of the pregnant mother prior to departure and then refused to transport her; in essence, they should have overruled the judgment of the physicians involved in the case. And they also ought to have resuscitated the child as well as any tertiary care NICU. Even though they weren't physicians. While in a speeding ambulance.

But we don't need tort reform, right?

Wednesday, June 30, 2010

The Palin Pregnancy

I'm sorry, but I just cannot resist any longer. The fantastical, magical realism surrounding the events of the birth of Sarah Palin's 5th child Trig just have to be reviewed. (Come on, there's a medical slant to the topic, right???)

Please take a moment to listen to or read the transcript of an interview ex-Governor palin gave to a reporter in 2008. To recap:

In April 2008, Sarah Palin was 43 years old and 8 months pregnant with a known Down's Syndrome child. She had had two previous miscarriages. For some reason she flew to Dallas, Texas to give a speech at a national governor's conference. Early in the morning on the day of the speech, Mrs. Palin states that she started to feel some cramps and noticed leakage of some fluid. So she called her OB in Alaska who apparently reassured her that everything was cool (and who now refuses to speak to anyone from the media about the incident). Again, she describes fluid leaking from between her legs, suggesting a possible premature rupture of membranes (i.e her water broke). While 8 months pregnant with a special needs child. At age 43.

Well that was again if, if I must get personal, technical about this at the same time, um, it was one, it was a sign that I knew, um, could lead to uh, labor being uh kind of kicked in there was any kind of, um, amniotic leaking, amniotic fluid leaking, so when, when that happened we decided OK let’s call her.

So Palin delivered her speech. She then elected to skip the post-speech reception (sort of awkward mingling at a cocktail party with amniotic fluid running down your leg, you know), got on a plane and flew to Seattle, Washington. She then took another plane to Anchorage, Alaska. Finally, she drove the 50 or so miles from Anchorage to Wasilla so that her fifth child could be born in his hometown. (Can't have no fishpickers born down there in the Texas!)

Digest that for just a second. A 43 year old woman carrying a child with known Down's Syndrome in her 8th month of pregnancy voluntarily embarked upon a transcontinental adventure to give some dumb speech. Then, after noticing some cramps and the passage of amniotic fluid, she went ahead with her speech and, instead of proceeding directly to the nearest Dallas high risk pregnancy center, boarded a four hour flight to Seattle. Then she hung out in the Seattle airport lounge for a while and took a connecting flight to Alaska. Then she drives to Wasilla. Finally, she decides to seek medical attention at local Wasilla hospital, a facility lacking a NICU and other high risk specialists. That's her story. In her own words.

There are only three explanations for this extraordinary compendium of events:

1) The Andrew Sullivan Answer: In this theory, Palin was never pregnant and Trig is not her child. To me, this is the least valid of all the theories. The odds of a woman giving birth to a child with Down's Syndrome increase with increasing maternal age. Again, she was 43 years old. I just don't buy it. (But a simple confirmatory birth certificate would be nice!)

2) The Mommie Dearest Answer: In this theory, everything that Palin says is true. In other words, Palin willfully and wantonly placed herself and her unborn child in tremendous danger by flying cross country with amniotic fluid running down her legs. This to me is the scariest possibility because by willingly telling the story, she seems to be under the impression that people would be impressed by her "hardiness" and "toughness". (That's the way we do things up here in the Alaska!) And she is completely oblivious of the fact that this story makes her look reckless and selfish and completely insane. What kind of mother would take a risk like that with her child, let alone a high risk, premature one?

3) The Bridge to Nowhere Answer: The other possibility is that she simply lied. She made it all up. She thought it would make her look tough. So her water never broke. She never felt cramps. None of these things actually happened until she was in Alaska. I suppose this one, banal as it is, represents the most likely answer.

Again, this woman is a major political player in the GOP. She could easily win Iowa and New Hampshire in 2012. She's frightening....

Monday, June 28, 2010

Work Hours Ctd.

Th ACGME has come out with new and improved recommendations for resident work hour restrictions. Some highlights:

*Interns have to inform patients of their role in patient care (i.e... Although I'm wearing a white coat and a stethoscope around my neck, I'm a pretty green neophyte at this whole doctoring business. Just thought you'd like to know. Enjoy your chicken broth and cold coffee.)

*Interns cannot work more than 16 consecutive hours. Fortunately, the ACGME chose not to co-opt the Institute of Medicine's (IOM) recommendation that residents are allotted time for a five hour nap period after 16 hours or work. Because that's just, you know, sort of embarassing. Because then you have to assign blankies and pillows to all the fresh faced interns and make sure snackies are available in the call rooms and it just becomes a logistical nightmare for residency program directors.

*According to the wording of the ACGME report, it appears that interns are not allowed to do anything involving patient care without "level 1 or 2a supervision". That means the attending physician either has to be standing right next to the young doc or at least somewhere on the premises. So all those central lines and chest tubes and code blues that happen in the middle of the night have to be handled by older residents.

Ah, the slow death of general surgery....

Sunday, June 27, 2010

What Does Dave Weigel have to do with Sermo?

Dave Weigel is a libertarian, right-leaning blogger who had been writing for the Washington Post. Although his politics veer right of center, he has no tolerance for the radical, wacky wing of the Republican Party (think Tea Partiers, Glenn Beck, Sean Hannity, etc.) Weigel was a member of the liberal-leaning listserv called JournoList (a private, by-invitation-only email group comprised of professional journalists and bloggers). JournoList provided a forum for these guys to exchange ideas with one another in an off the record fashion. Weigel, this week, in a moment of reckless writing, posted a thread on JournoList implying that the world would be a better place if Matt Drudge suddenly decided to self immolate.

Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.

The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)

Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.

What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.

Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....

Friday, June 25, 2010

Drug Testing Docs?

I got this link from Sermo. Lucian Leape MD, a public health professor at Harvard, wants to subject doctors in America to strict random and periodic drug testing to help identify those physicians who are impaired. All in the name of patient safety, of course:
"I'm very much in favor of random testing," Dr. Leape says. "We have a responsibility to identify problem doctors and bring them into treatment." And to protect patients in the process.

Ok, I get it. Impaired physicians are bad. We don't want strung out cokeheads and stumbling alcoholics roaming the halls of our hospitals. But random drug testing? Listen, it's hard to argue with someone like Dr. Leape without appearing to be some uber-lefty, bleary eyed, tie-dye wearing hippy freak. But consider:

1) A doctor who is on vacation with extended family in the Outer Banks. After a day of surfing and tanning and several cold frosty beers, one her cousins busts out a joint late night on the back deck while the ocean rolls into shore. And let's say she partakes in such activities 3 of the next 4 nights in similar fashion. That THC will be floating around in her system for the next 30 days, potentially. What if she is called to give urine a week after the trip?

2) Let's say an internist goes to a Super Bowl party with friends. The day turns into an all night fiesta as they celebrate the Browns' first ever world title. Many beers are consumed. Knowing that it was going to be a long night of carousing, the doctor had cancelled his office hours for the following Monday morning, planning to just drop by the office in the afternoon to do some charting. The next morning, his office manager calls at 8 AM sharp and tells him he has to have his urine/blood sample in by 10AM. He stumbles out of bed, still hung over, and rushes into the hospital. The result shows his blood alcohol is 0.09 (enough to get you a DUI). What do you do with him?

What are the consequences? Do you lose your license? Are you reported to the medical board? Are your privileges at hospitals suspended? Does your name wind up on the police blotter section of your local Sunday paper?

To be clear-- I am strictly against the idea of physicians practicing medicine while impaired. But this totalitarian encroachment on what a man or a woman chooses to do in his/her free time is rather disturbing. As a professional class I think it is our own responsibility to identify and report those doctors who have a problem. An impaired physician cannot hide for very long. We just need to stop being such timid cowards and do a better job of self-policing ourselves.

Wednesday, June 23, 2010

Work Hour Reform Redux

Kevin has a good article in the USA Today about the negative consequences of resident work hour reform. In it, he notes that patient "hand off" errors and the lack of operative exposure a surgeon-in-training gets during residency can adversely effect both patient care and the ability of future doctors to handle complex situations.

I also just read a crappy paper in Archives about the effects of the 50 hour work week limitation currently in use in Switzerland. The overwhelming majority of attending and resident physicians stated that the reforms negatively affected operating room experience and overall patient care. Who would have thought that working as much as a middle manager at a Toyota plant would adversely effect a surgeon's training and performance.

If you live in the Atul Gawande world, none of this bothers you. In this world, sub-sub specialist physicians are only responsible for a tiny sliver of medical knowledge and so there's really no reason to be spending 100 hours a week in a hospital during your training. A fully integrated, multidisciplinary "system" will take care of everything. You won't need a general surgeon. The thyroid guy will take out your thyroid gland. The biliary guy will remove your gallbladder. And the colorectal guy can take care of your hemorrhoids. Don't you worry.


Sunday, June 20, 2010

Happy Father's Day

Ok, so I've obviously decided to continue churning out a mixture of pithy anecdotes and other assorted detritus on Buckeye Surgeon. Thanks to all who commented, either on the post or via email. As my buddy Goose wrote: "nice to see you've snapped out of your early mid life crisis and are back blogging."

I've been reading William Shirer's Rise and Fall of the Third Reich lately. (It's long, but reads like a Tom Clancy thriller. Just fascinating that an entire nation could fall under the spell of a complete and utter lunatic.) Anyway, there was a part describing one of the speeches Hitler gave to the Reichstag in 1938. He used the occasion to respond to FDR's official query into his intentions with regards to several of the other remaining free nations in central and eastern Europe. Hitler had already secretly obtained declarations (in the gentle, diplomatic Nazi way, you can be sure) from those countries announcing that none of them had any fear of further German aggression. He then proceeded to mock Roosevelt in faux indignation. How dare the President of a country that just ended slavery a generation ago, a country that liquidated/relocated the native population to allow for the Manifest Destiny of its white pioneers, how dare they lecture Germany on good behavior. Apparently this set off thunderous applause and laughter throughtout the Reichstag.

Hitler hadn't really scored any real points with this line of thought, of course. One doesn't lose all moral credibility just because of past transgressions. You don't lose the right to call out someone for immorality or an ethical lapse just because you have sinned in your own past. You only lose it when you fail to ackowledge your past failures. Atonement is impossible without an honest self-interrogation. And I guess that was the point of my little blog sabbatical and the subsequent to be or not to blog post. As my fantasy football friend Jeff said: it's about time you wrote a self critical post contra the shiny white knight of compassion you've created on the blog. What took you so long? What kind of self-loathing post-modernist would you be otherwise?

I guess that's part of it. But not all. I'll be honest---I write this thing for my little baby girl, mostly. I want her to have a way to find out what I was like and what I thought about when I was younger man. It's corny, I know. But I dont care. Go read Kevin MD if you dont like it.

Gawande on the Matrix

Atul Gawande gave the commencement address at Stanford medical school this year. I thought it might be fun to rip-off a Bill Simmons schtick and do a retro-diary of my thoughts as I read through it. So here goes. (Text borrowowed from the New Yorker.)

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.
(Frank Drackman additionally received a Masters of His Own Domain upon graduation)

So why—in your heart of hearts—do you not quite feel that way?
(Because we just finished the entirely useless, waste of time, summer vacation known as fourth year of medical school!)

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
(I use the word 'microarray' at least 17 times a day)

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
(When I was 11, my older cousin Chris told me all about his girlfriend's velluvial matrix. I acted like I knew exactly what he was talking about.)

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”

I was stumped. The information was not anywhere in the textbooks.

“I don’t know,” I finally confessed.

“What kind of doctor are you?” he said.
(Now come one. Solar plexus? Did this anecdote really happen? And was Gawande truly upset that he didn't know the location of a solar plexus? Did he crack open his anatomy textbook, frantically leaf through the index searching? In the words of my pretentious feminazi freshman English comp instructor---it just doesn't "ring true".)

I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.
(Damn. Don't I feel like an ass after all those anti-Cost Conundrum posts. I hereby retract all jokes re:Gawande. The dude's had a tough life.)

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
(Now we get into the meat of his point--that the complexity and depth of modern medicine is "too much" for the individual physician. More on this later.)

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.
(Service line? Why are we using corporate jargon all of a sudden?)

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.
(This part seems forced and a little disingenuous. The multitude of diagnoses and treatment options available to doctors today does not necessarily demand instantaneous memorized command of all facets of medicine. I have no problem using these things called the "internet" and "medical textbooks" to read about topics I don't know or have forgotten. For big cases I prepare by reviewing the surgical atlas and reading up on the latest literature. For management of hypertensive crisis in the ICU, I quickly log on to UpToDate and then call back the nurse with an answer. It doesn't take long. Just because the answer to a patient problem initially eludes you, it doesn't mean you have to throw your hands up in the air and retreat to the safety of the "50 or so diagnoses you are comfy with".)

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
(Yes, occupying three countries half way around the world is a mere drop in the pan of federal spending!)

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
(Aha! It seems the good doctor has backed off a bit from his conclusions in the Cost Conundrum article that communities that spend more per capita on healthcare have worse outcomes. Now he hedges a bit, using the modifier "sometimes" to describe discrepancies in health care spending as they relate to outcomes. See this for details.)

Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.
(For now on, all doctors who practice in a hospital setting need to meet for three hours every other Monday morning with representatives from ancillary care, hospital administration, nursing, physical therapy, food services, patient transportation, the candy stripers, the old lady who brings around the gentle giant siberian husky petting dog for patients to touch, janitorial services, etc for a collegial intradiscplinary staff meeting to discuss ways of enhancing hospital teamwork.)

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.
(And if you take the engine of a Pinto, the body of a Edsel, the transmission of any 1980's era Chevrolet you get: a very cheap and ugly piece of shit.)

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reĆ«xpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
(Ok. Now we have to interrogate this line of thinking. No more jokes. Gawande seems to be advocating for an algorithmic, systems-based paradigm of medicine, one in which the parts, i.e physicians, are mere cogs in some sprawling, evidence-based machine of health care delivery. There are too many diagnoses, too many treatment options, and too much innovation to be apprised of, as individual doctors. Therefore, we need to limit our spheres of responsibility. A specialist for every facet of health care. Blood pressure too high? Go see a cardiologist. That rash you got after hiking in the woods? Go see this dermatologist. Need your thyroid removed? Go downtown to see the endocrine surgeon. This is an attack on generalists, an attack on the idea that an individual doctor, dedicated and intellectually curious, can provide optimal care for his/her patients. And the example he provides of Duane Smith seems to paradoxically repudiate his entire theorem. All these good doctors working together but somehow they all forgot to prescribe the necessary vaccination. Gawande would say that the problem lay in an inappropriately designed and monitored 'system'. I would counter that the component parts, the doctors, individually failed the profession and henceforth the patient. How do you forget to give Pneumovax after taking out a spleen? That's simply bad doctoring. That's a general surgery 101 exam question.)

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.
(This resigned attitude to the impossibility of staying up to date on the latest medical developments is saddening. I don't know what to say. Maybe I'm just a 37 year old dinosaur.)

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.
(Yikes. That last sentence evokes an uneasy Orwellian utopia. Do I have to report to room 101 for a session with O'Brien if I write for Nexium instead of Prilosec for GI ulcer prophylaxis on a post op patient??)

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.
(Subsume the individual into the Great Intradisciplinary Whole! The Maoist in me is feeling warm and fuzzy right now. But seriously, it's one thing to encourage greater communication between different specialists and to penalize those docs who are doing unnecessary procedures just for the compensation; it's quite another to throw in the towel on individual accountability and the ideal of the dedicated, astute physician who always strives to do the right thing for his/her patients. Kierkegaardian Individual Ethos trampled under foot by Henry Fordian mechanization and interchangeable parts! Listen, we don't need a brand new system or a restructuring of some quasi private/public healthcare bureaucracy. We need better doctors. We need to inculcate a stronger ethic of personal responsibility, both to our patients and to the health care system as a whole. I've said it a million times in this blog--- becoming a doctor ought not to be some default pathway for high achieving college kids who can't decide what else they want to do. It's a hard job, but rewarding as hell when you approach it with the right mind frame.)

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
(I can't argue with those sentiments.)

This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.
/mass of students toss grad hats and gowns in the air and charge out of locker room screaming and yelling like banshees into the Pacific Ocean and swim for an undeteremined hospital in China.
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